Jerawat

Acne vulgaris or commonly known as acne is a chronic inflammatory skin disorder that results in plugged pores and outbreaks of lesions. It affects all ages but it is most common amongst adolescents and young adults and it affects both boys and girls. It is a disorder of the sebaceous glands (oil glands) that secrete an oily mixture called sebum. Sebum is a fatty substance that lubricates hair and skin and keeps them supple and healthy. Acne is not considered as a serious health problem but severe cases of acne can lead to disfigurement and scarring that can be very distressing especially to the teens.

Introduction to Acne

Acne is a common skin condition of people in their teens and twenties. However it can occur at any age and is very common in the newborn as early as 2 weeks to 2 months of age. Adults in their 20's can get acne and in a more severe form. It can continue up to about 40 years of age or even beyond, especially in women who have premenstrual exacerbations (flare-ups). It is a common skin condition, so common that it can almost be considered as part of a growing up process.

It develops in the pilosebaceous follicles of the face, neck, chest, shoulder and even upper arms and back. It can present with whiteheads, blackheads and inflamed papules. In severe cases there are nodules, large cysts, painful swellings and scarrings. It can be severe in up to 5% of all individuals. It often clears up after several years even without treatment. Acne can be very distressing and disfiguring especially if it occurs on the face leaving permanent scars.

Non-inflammatory acne - The basic or the smallest acne lesion where the follicle passage is plugged with bacteria and oil is called the comedo or comedone. A closed comedo or a whitehead is a comedo whose opening is not widely dilated, appearing as a small, flesh-coloured papule; because the keratin and sebum produced and cannot escape. It may rupture and cause an inflammatory lesion in the dermis. A comedo that enlarges and bulges out of the skin surface and opens up it is called an open comedo or a blackhead. The dark colour is due to a build up of skin debris, oil and skin pigment called melanin.
Inflammatory acne - When a follicle gets clogged up with the accumulation of sebum it encourages the bacteria that normally live on the skin, called Propionibacterium acnes (P. acnes) to grow rapidly. These bacteria produce chemicals and enzymes that can cause inflammation and swelling in the follicle and the surrounding tissues. Basically, there are 3 types of inflammatory acne:
- Papules (typical pimples) mildly inflamed lesions with small, firm and reddish bumps and boils on the skin.
- ustules - small round lesions filled with pus underneath the skin surface.
- Nodules - sometimes referred to as cysts. Nodules develop when the comedo builds up and ruptures causing the follicle to break open and spill up into the surrounding tissues of the skin. These lesions can extend deep into the skin causing pain and scarring.

The skin is the largest organ of the body by weight and surface area. Technically, the skin consists of 3 layers. The outermost layer which is the thinnest layer of the skin is called the epidermis. The epidermis consists of many layers and 3 types of cells which protect us against ultraviolet radiation and foreign substances from penetrating the skin. The epidermis also produces the hair and nails. The middle layer which makes up about 90% of the skin's thickness is called the dermis. The innermost layer is the subcutis (underskin). The dermis is composed of connective tissue, blood vessels, nerve endings, hair follicles and sweat and sebaceous glands. These glands are embedded in the dermis attached to the hair follicles and are found over most parts of the body.

Acne is a disease of the sebaceous glands and hair follicles. The function of sebaceous glands is to produce a special protective substance called sebum, an oily substance that also contains waxes and lipids. It lubricates and maintains hydration of the skin and hairs and makes skin soft and healthy. When the sebaceous glands secrete the right amount of sebum, it flows out through the follicle and pore to the skin surface. When this path gets blocked the flow of the sebum will be obstructed from reaching the skin surface. This will lead to the formation of acne. Thus, the two main factors which lead to the formation of acne are the obstruction of the sebaceous duct and the increased sebum secretion. Both factors are influenced by hormone levels. These conditions are very common among teenagers at the time when the sebaceous glands start to function and male and female hormones kick in.

The clogged-up passages or pores may be due to deposition of dead skin cells, bacteria, hormones or too much sebum. If the obstruction takes on a dark pigmentation, the top surface gets darkened and is visible and is called a blackhead. If the blockage occurs under the skin and is invisible and the collection of sebum appears as a small white lump bulging out, it is called a whitehead. If the obstruction is tenacious, the sebum gets piled up causing the gland to rupture. The affected area will appear red, swollen and is often painful. There will be presence of pus. Sometimes, there is a break in the walls of the follicle, allowing the sebum, bacteria and dead skin cells to spill beneath the skin causing a red infection, swelling with pus called a pimple. If it happens deep inside the skin it can lead to cysts.

What are the causes of acne?

The exact cause of acne is not known but it is believed to be the result of a combination of several related factors, such as:

Hormone production - the increased production of male sex hormones called androgen during puberty in both sexes causes the sebaceous gland to enlarge and produce large amounts of sebum. When the hair follicles get blocked, acne can develop.
Hormonal change - It may occur in adult women as a result of hormonal changes especially during menstruation and pregnancy. Many of them notice that their acne gets worse 3 to 7 days before their menstruation starts. For others pregnancy triggers the reactivation of acne or makes the existing condition worse .
Hereditary - certain people have a genetic predisposition for acne if their family members have it. "Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many school-age boys with acne have a family history of the disorder".
Maternal hormonal imbalance - this will cause neonatal acne in infants due to the hormones that they get from mothers in the uterus and through breastfeeding. Once the breastfeeding stops the acne will clear up.
Side effects of certain preparations - acne can also occur as a result of reaction to certain types of oil based cosmetics, toiletries, skin preparations, shampoos. Cosmetic acne is normally caused by greasy cosmetics that contain linolin and vegetable oil bases such as foundations, night cream and moisturisers. This type of acne can be very persistent and sometimes lasts for years.
Drugs - drugs such as bromides, lithium, steroids (corticosteroids), androgenic hormones, oral contraceptives, barbiturates and antiseizure medication can make acne worse.
tress - severe stress or prolonged emotional tension can have physiological effects on the body which induces higher levels of hormones. It increases sebum production, leading to clogged pores and may significantly affect acne. It has been reported that certain people claim their problems worsen during stressful conditions and get better when their lives becomes more stable. " Studies have also shown that the body produces more androgen when a person is under stress. The increase may trigger acne flare-ups by stimulating the sebaceous glands to pump out more sebum. Even physical stress such as colds, allergies, surgery or menstruation can trigger break-outs".

It is interesting to note that poor hygiene does not cause acne, although a build-up of oil and dead cells on the skin surface may increase the risk of blocked follicles and allow bacteria to multiply. There is no evidence that fatty foods, candy, or chocolate either cause or aggravate acne.

Those who are genetically predisposed are at risk of getting acne
The use of certain cosmetics such as creams, oil based moisturisers, oil based foundations, blushers.
Use of certain types of drugs such as steroid (cortisone), anti-seizure medication, lithium, iodides, and oral contraceptives can also put one at risk for developing acne.
Exposure to environmental agents such as grease, and solvents can cause acne as well. "People who work in chemical or oil industries and come in contact with hydrocarbons, heavy oils, cutting oil, wax, grease and coal tar derivatives can develop acne" .
Stress can affect acne. Changes in hormone levels can trigger the sebaceous glands to enlarge and produce more sebum which causes acne.
People working in hot and humid climates are also at risk of getting acne.

Malaysian statistics on acne is not available. Most patients with mild cases of acne do not seek medical attention and many of these patients use home remedies and over the counter (OTC) medications. The incidence of acne appears to be the same for both sexes. The disease is more serious and extensive in boys than girls. "Acne vulgaris typically appears at puberty, normally a year or two earlier in girls than boys. At the age of 16, some degree of acne affects 95% of boys and 83% of girls. Peak incidence is 14 - 17 in girls and 16 -19 in boys". (Index of Disease - Encyclopaedia of Medicine in Inside Human Body, Bright Star Pub.,UK,London, 2000).

In the UK , "The Proprietary Association of Great Britain's survey in 1988 found that 35% of males and 41% of females aged between 15 - 19 had acne symptoms in a two-week period". (http://www.dotphamacy.co.uk/upacne.html). "In a British study in October 1999 edition of the American Academy of Dermatology, 12 % of women over the age of 25 had visible facial acne. The percentage of women affected didn't start to drop dramatically until after the age of 44 according to the study"

" Nearly 17 million people in the United States have acne, making it the most common skin disease" . Acne is also quite common among adults. "According to the National Institute of Health, 85% of adolescents develop acne. Among adults, 12% of women and 3% of men have acne. Indeed, acne is the most common skin disease in the United States ". " In a study published in the October issue of the Journal of the American Academy of Dermatology found that of 749 adults between the age of 25 and 58, 54% of women and 40% of men suffered from some form of acne in both sexes did not decrease substantially until after the age of 44".

What are the symptoms ?

It is quite common for agne vulgaris to localise in a particular area such as the face, shoulders, neck and upper trunk. The physical signs and symptoms include:

Presence of skin rash or persistent, recurring reddish blemishes on the face and may be other areas such as the chest, shoulders, neck or back.
The affected area of eruption is frequently greasy.
Tiny dark coloured spots with an opening called blackheads and small and firm spots that bulge beneath the skin with no opening called whiteheads appear on the affected sites.
If the inflammation continues there will be redness of the skin lesions called pimples, often with yellow pus-filled tips which can lead to papules and nodules.
Often they are painful.
Redness, swelling and pus-filled lesions accompany infection leading to skin eruption.
Tender lumps beneath the skin without obvious heads (cysts)
In severe cases when the cysts heal, deep pitted scars can be left behind.

It is necessary to take swabs to exclude other skin infections such as pyogenic or anaerobic infections and Gram-negative folliculitis. "In cases where there is a history of menstrual disturbance or clinical evidence of virilisation, it is necessary to exclude the polycystic ovarian syndrome, an androgen-secreting tumour and congenital adrenal hyperplasia. In such cases serum testosterone, sex hormone-binding globulin (SHBG), luteinising hormone (LH) and follicle-stimulating hormone (FSH), androstenedione (A4), dehydroepiandrostenedione sulphate (DHEA[S] ) and 17-hydroxyprogesterone levels should be measured". ( Haslett.C.,et al, 1999) Pelvic ultrasound may be useful to trace ovarian cysts. "An appreciable number of patients with acne have ultrasound evidence of ovarian cysts without biochemical evidence of polycystic ovarian syndrome" ( Haslett.C.,et al, 1999). Very rarely a skin biopsy is carried out to confirm the diagnosis.

What other conditions can mimic acne ?

Clinically, acne vulgaris is a quite clear cut and obvious skin condition. Other skin conditions that should be considered in differential diagnosis, include:

Rosacea - is a chronic inflammatory disorder which is characterised by a persistent facial eruption and presence of diffuse erythema. Sometimes accompanied by papules and pustules. Sebum secretion is normal. The cause is unknown. "The cause may be related to vascular damage from ultraviolet or infrared radiation, release of inflammatory chemicals in the skin, or even a mite" . The condition is most common in middle age and commonly seen on the cheeks, chin and central forehead. "Its late onset and absence of comedone differentiate it from acne vulgaris". It is usually treated with long term antiobiotis and low potency steroids.
Acne Keloidalis - Commonly seen in people with tightly curled hair especially the Afro-Caribbean origins. The growth of their hairs is said to penetrate into the follicular wall causing the blockage of the follicle, thus preventing sebum from reaching the skin surface. Treatment involves keeping the affected area clean and removal of the affected hairs. sis.

Self-help measures may help clear up mild acne and prevent recurrence (see Self Help below).

There has been a lot of progress over the years in the treatment of acne. Various treatments, either topically or orally are available over the counter (OTC) as well as with prescription. The doctor may prescribe topical or systemic medication or a combination of both. The main goal of treatment is to reduce the number of lesions and to prevent scarring, thus minimizing the psychological stress and embarrassment. Treatment takes time and it should be continuously followed as acne improves. If your acne does not heal after 6 to 8 months, you may need to change your treatment. However, treatment varies according to the type of acne. Most acne treatment lasts from months to years.

The main aim of pharmacological treatment is to control the growth of bacteria and to reduce the activity of sebaceous glands in the skin. Your doctor or dermatologist may prescribe one or a combination of the following treatments depending on your condition.

This therapy is applied externally on to the skin not just on the lesion but the whole of the affected area. Topical medications can come in various preparations such as lotions, creams, gels or soaps. They are mostly OTC medications. Some of the side effects of this type of medications are mild irritation of the skin with some scaling, stinging, burning, peeling of the skin and redness of the affected areas. Reducing the number of applications will improve the condition. Patient should be reminded that topical preparations might take between 4 to 8 months to show improvement. Among the topical medications are:

Benzoyl peroxide - It acts to destroy the P. acne bacteria that causes acne by penetrating into the follicles and releasing hydrogen peroxide. Hydrogen peroxide will inhibit acne formation. Benzoyl peroxide is a kerolytic or a drying agent that helps to dry the skin and opens up the pores and peels off the dead skin cells from inside the hair follicles, thus preventing plug formation. It comes in various strengths, 2.5%, 5% and 10%. Patients should be advised to start with low strength 2.5% concentration to prevent irritation. The strength can be increased gradually. In mild cases of acne benzoyl peroxide can be used as monotherapy and as an adjuvant in moderate to severe cases. It is available in combination with topical antibiotics such as erythromycin (Benzamycin) and clindamycin (Benzaclin), hydrocortisone and sulfur.
Salicylic acid - this preparation helps to correct abnormal shedding of cells. It unblocks clogged hair follicles, resolves and prevents lesions. It comes in the form of lotions, creams and pads. It must be used continuously for a long period of time. When you stop using it, acne will recur.
Topical retinoids - Retinoids are vitamin A derivatives and are effective in treating blackheads and whiteheads. Topical retinoids are comedolytic and they prevent the formation of plugs by peeling off the skin cells from the hair follicles. It helps to stop the development of new comedones. It is available in gels and cream bases. The common side effects are dryness and irritation of the skin.
Azelaic acid - It is a safe topical application which can be given to pregnant women. It helps to stop or slow down the growth of P. acne and reduces inflammation. It should be applied twice a day. It is used for treatment of mild comodonic to moderate papulopustular acne. It is available in cream bases. It has very few side effects such as minor degree of skin irritation.
Topical antibiotics - These are used for the treatment of mild to moderate inflammatory acne. This type of medication is less effective in inhibiting P. acne as compared to benzoyl peroxide. Some of the topical antibiotics are erythromycin and clindamycin.
Topical steroids - These are effective anti inflammatory agents and are used to treat mild to severe inflammatory acne. However, long term use is not advisable in acne patients. They are sometimes added into proprietary preparations.

This is a medication taken by mouth (orally). This type of treatment is normally given when topical medication fails or is impracticable because of widespread disease or where there is scaling. Sometimes, the doctor may suggest using both topical and systemic medication at the same time.

Oral antibiotics - The doctor may prescribe oral antibiotics for severe cases of acne. Antibiotics act by curbing the growth of P. acne and decreasing inflammation. Among the common oral antibiotics prescribed are tetracycline, minocycline, doxycycline and erythromycin. These drugs are safe and can be continued on a long term basis, if indicated. However, long term antibiotic therapy may create further complications, such as Gram-negative folliculitis and drug resistance to treatment. Some antibiotics(tetracycline and minocycline) may interfere with oral contraceptives and their effectiveness. Other mild side effects include photosensitivity (sensitivity to the sun) and darkening of the scars, dizziness, and stomach upset. Normally, patients have to take oral antibiotics for as long as 4 to 6 months in order for treatment to be effective.
Isotretinoin (Accutane) - is a retinoid and is taken orally. It is a very effective medication for severe persistent acne and helps to prevent extensive scarring in patients. It is usually prescribed when other types of medication fails and is given for a long period of time between 16 to 20 weeks. It acts by reducing markedly the size of the sebaceous glands and thus less sebum is produced. It also prevents stickiness of cells in the follicles, thus helping to prevent the development of new comedones. Normally, this drug has to be prescribed by a dermatologist because it is not only expensive but also quite dangerous to be given to some patients. It is teratogenic- that is, it can cause birth defects if given to pregnant women. It is therefore, important that women who are on isotretinoin should not get pregnant. "Women must use an appropriate birth control method one month before therapy begins, during the entire course of therapy and for a full month after the therapy stops". This side effect normally stops when the medication is terminated.
Oral contraceptives - are usually used for treatment of moderate acne caused by excessive production of androgen. This drug helps to suppress this hormone which is produced by the ovaries. It is a low dose oestrogen and is given to female patients only. Its action is to reduce excessive sebum production. It is a long term treatment and it may take 12 to 36 months to complete the course. "In clinical studies, improvement of acne was reported in more than 80% of the studies' participants. The serious side effects include blood clots, stroke and heart attack and increased risk of breast cancer, particularly at a young age". Oral contraceptives also help " to regulate a woman's hormones and reduce acne by up to 84%, according to a University of Illinois at Chicago study published in the April 2001 Obstetrics Gynecology."

Most patients with acne respond well to standard treatment. Patients have to be educated on treatment and its modes of action which will lead to greater patient compliance and a better outcome for them.

Removal of acne sebum through face cleansing once or twice a day with ordinary soap and water.
For infected cysts, Incision and drainage of cyst and needling abscess under local anaesthesia may be necessary.
Laser surgery (laser resurfacing) may be performed to improve unsightly deep scars and pigmentation. The strength and intensity of laser used to contour scar tissue and to reduce redness around the lesion may vary according to the type of scar. A laser is applied all over the skin, removing the upper layers and causing them to scab and fall off. A new more elastic skin grows in 7-10 days.
Use of comedones extractor may be recommended for patients with multiple macro-whiteheads and blackheads.
Photorejuvenation - Intense pulsed light is filtered into the skin which remoulds the collagen and shrinks the skin. Broken capillaries absorb the light and shrink, dark facial hair absorbs it and pigmentation is broken up and absorbed.
Dermabrasion (skin layer removal) is used for the treatment of depressed scars. It is done under local anaesthesia where surface skin is removed to repair the contour of scars. Superficial scars may be removed but deep scars may be reduced in depth. For dark coloured skins, pigmentation change may require additional treatment. Thus, it is not used for all types of acne scars and in certain countries like the UK it is rarely done nowadays.
Chemical peels - A chemical is applied to the skin that removes several layers, exposing a fresh layer of new and undamaged skin. Strengths and depths of peels vary according to your needs and whom you consult.
Skin surgery - this procedure is carried out to treat ice-pick scars which are removed individually by excision down to the subcutaneous fat. Subcission is done to remove the scar tissues among the healthy skin, thus elevating a depressed scar.
Skin grafting - this type of treatment is done to close uproofed scar tracts caused by inflammatory reaction to sebum and bacteria in the follicles.
Cryoslush - this is a cryosurgery using carbon dioxide to treat active acne and superficial acne scars. This is a cold treatment and is prepared under -700C. It is then applied to the affected skin to destroy comedones. It causes superficial peeling of the skin but it does not produce side effects. It is good for cosmetic purposes.
Autologous fat transfer - fat is taken from another part of the body and then prepared specially for use as injections. It is injected beneath the skin surface to raise the depressed scars. This method of treatment is performed to treat deep contour defects caused by scarring from nodulocystic acne. This treatment takes some time to produce the effect which is very promising.
Reassurance - this is a very important aspect of patient care. Patients have to be informed and reassured that acne is curable and complete healing in most cases is possible but it takes time. The most important thing is to reassure the patient that she or he is not the only person in this situation.

Perioral Dermatitis - usually results from prolonged treatment with potent topical corticosteroid therapy. Commonly occurs among young women and is characterised by the presence of papules and pustules. Withdrawal of the topical steroid will improve the condition.
Steroid Acne - caused by corticosteroid therapy. Commonly appear on the face, upper chest and back. The treatment is the same as above, that is by stopping the use of steroid therapy.
Gram Negative Folliculitis - it is a complication due to prolonged use of broad spectrum antibiotics for acne. Lesions are seen around the nose with the presence of pustules and deep seated nodules. Treatment is usually by giving appropriate antibiotics, for example ampicillin.
Scars - Patients with severe acne who are not treated properly often develop scars. These scars are difficult to treat. There are two types of scars:
- Scars caused by increased tissue formation such as keloids or hypertrophic scars.
- Scars caused by loss of tissue, such as:
- Ice pick scars which occur on the cheek.
- Depressed fibrotic scars
- Soft scars (superficial or deep)
- Atrophic macules - commonly found on the chest and back.

Following these simple self-help measures may help clear up acne and prevent further episodes:

Most acne treatments require prolonged care lasting from months to years. As such, patients need to be monitored especially if they are on certain oral medication such as antibiotics, oral isotretinoin etc, to prevent serious side effects and complications.

Female patients who are on oral isotretinoin (Accutane) are to be monitored closely so that they do not get pregnant and they continue to use reliable contraceptives. For such patients regular pregnancy tests or monthly review is advisable. A number of blood tests should also be carried out before the drug is given to them. It is also necessary to monitor periodically complete blood counts, blood chemistries, cholesterol, urine and liver function tests during the therapy because this drug can lead to an increase in blood cholesterol, triglyceride levels and abnormal liver enzymes.
Patients on long term antibiotic treatment are to be monitored from time to time to prevent drug resistance and development of Gram-negative folliculitis.
Patients on contraceptives undergoing long term treatment of acne need to be monitored too for serious side effects such as blood clots, development of stroke and increased incidence of breast cancer.

Acne is not a life threatening condition. However, it can lead to serious and permanent scarring which can be very upsetting and disfiguring. Acne can last for many years but with proper treatment along with other control measures, the prognosis tends to be very good as the majority of patients respond well to treatment. "90% of patients show a 50% improvement in 3 months and 80% improvement within 6 months, but continuous treatment is necessary for many years".

Acne is usually one of the easiest skin conditions to treat, but has to be treated earlier to minimise the risk of scarring. Remember that there is no fast or permanent cure for acne but it is controllable. If acne has already left noticeable scars, you may wish to consult a plastic surgeon and discuss techniques such as dermabrasion.

How can we prevent acne ?

Acne is not preventable. It can only be controlled. The control of acne is an on-going process. Preventive measures can reduce complications. You must continue to take care of your skin to assist in treatment of acne and speed up the healing process. Some of the preventive measures include:

Take care of your skin and wash your face with soap and warm water at least twice a day to remove surface oil, dead skin and dirt. Keep the skin slightly dry. Avoid active scrubbing which may aggravate the condition. Rinse the skin well after washing.
Use a dry towel to wipe your face, as wet or damp towel/cloth encourages bacterial growth. Change your face towel everyday.
Avoid heavy foundation make up, oily cosmetic or cream products that are irritating to the skin and comodogenic. Use only water-based make up and remove your makeup every night with soap and water.
Choose noncomedogenic cosmetics and toiletries.
Inflammatory acne should not be picked and squeezed as squeezing will force infected materials deeper into the skin and spread infection. This will cause more redness, additional inflammation, possible scarring and pigmentation.
If your hair is oily regular shampooing is recommended.
Men with acne should shave as lightly as possible and use a sharp blade.
Avoid things which can aggravate acne such as oils, airborne grease and irritating clothing.
Eat a healthy well balanced diet. Take more fresh fruits and vegetables. Drink plenty of water, 8 to 10 glasses a day. If certain foods make your acne worse, try to avoid them. But always remember that acne is not caused by the food you take.
Exercise regularly, at least three times a week and 20 - 30 minutes for each session. This will improve your blood circulation and bring more oxygen to your skin.
Avoid smoking, drinking and drugs. They are also culprits in causing acne. These substances tend to clog-up pores and cause acne. Smoking will complicate acne treatment.

Nevertheless, the only sure way of preventing complications such as inflammation that may lead to scarring is to treat acne early.